Senior Project FinalWORDPDF

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Effect of Physical Therapy on Post Operative Hip Osteoarthritic Patients
Senior Project Paper
Kinesiology and Health Promotion Department
Cal Poly Pomona, University
Winter, 2015
Kai Roach

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Table of Contents
Introduction Page Number
Statement of the Problem_______________________________________ 4
Purpose of the Study___________________________________________6
Significance of the Study_______________________________________ 6
Hypothesis __________________________________________________ 7
Limitations of the Study________________________________________ 7
Definition of Terms____________________________________________8
Literature Review
Hip_________________________________________________________11
Age_________________________________________________________12
Genetics_____________________________________________________13
Obesity______________________________________________________14
Range of Motion______________________________________________ 15
Treatment____________________________________________________16
Summary____________________________________________________ 18
Methods and Procedures
Subject Characteristics__________________________________________20
Location of Project_____________________________________________21
Treatment____________________________________________________ 22
Data Collection_______________________________________________ 27
Instruments Used______________________________________________27
Analysis of Data_______________________________________________28
Summary____________________________________________________ 29
Chapter 4
Age Comparison_______________________________________________30
Obese Comparison____________________________________________________________________30
Range of Motion Comparison_____________________________________31
Treatment Comparison__________________________________________31
Summary_____________________________________________________32 
Chapter 5
Conclusion____________________________________________________33
References____________________________________________________ 37

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Introduction
The circle of life is hardly ever fair, and as we age, life becomes increasingly difficult.
The effects of aging cause the human body to slowly deteriorate resulting in loss of bodily func-
tions and weakness. Muscular weakness is the most likely cause of injury due to increase stresses
placed across joint complexes such as the hip joint (Felson, D. T. 1996). The most common in-
juries that occur in the later stages of the human life cycle pertain to the muscular and skeletal
systems. Weakness in these areas can adversely affect ones quality of life. Elderly individuals are
more at risk to falls due to muscular and skeletal weakness which can lead to hip injuries (A.
Shane Anderson, Richard F. Loeser 2010). To prevent hip injuries, more aggressive approaches
such as total hip replacement surgery may be the best option. The most common reason for hip
replacement is osteoarthritis. When the cartilage covering the ends of the bones break down, the
bones begin to rub together which may create different growths. These spurs, which will form
around the joint will lead to pain and stiffness, making it very difficult to walk and limits range
of motion of the hip. The main risk factors leading to hip osteoarthritis are genetics, obesity, and
age. Although age, genetics, and obesity will not be specifically tested in this study, it is impor-
tant to understand their role in the development of hip osteoarthritis. While spending time at my
site, every patient located on the floor with osteoarthritis are obese and elderly.
The purpose of this project is to determine what effect physical therapy has on post oper-
ative hip osteoarthritic patients by examining patients range of motion. After completing the Se-
nior Project I will be able to determine if physical therapy helped patients regain some mobility
without exhibiting a great deal of pain. The patients with hip osteoarthritis were all

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treated similarly. Five patients were chosen for the project, however they will not be named due
to patient confidentiality. The patients varied in sex, occupation, severity, ethnicity, but were sim-
ilar in age. This project was completed through a clinical observation format of over 200 hours at
Inter- Community Hospital apart of Citrus Valley Health Partners, Orthopedic Surgery in Covina
and was Supervised by Melissa Halbert. There were four goals for the senior project: 1) Under-
stand the theory and application behind an initial evaluation, 2) experience how the patients
severity, age, occupation, and range of motion alter the rehabilitative process and treatment, 3)
assist in the rehabilitative process, 4) improve my ability to interact with patients. The goals of
this project were met by coordinating with the clinical supervisors to volunteer on the days and
times that the chosen patients were available for treatment. Observation of the rehabilitation
process and discussion with the physical therapist as well as physicians, nurses and patients was
also used to meet the goals of this project.
Statement of the Problem
The Orthopedic Surgery floor located at Inter-Community Hospital in Covina is full of
patients, however they all share a common modality. Every patient on the floor has hip problems
relating to hip osteoarthritis or fractures. Most of the patients need hip replacement surgery. The
focus of the project is Total Hip Replacement surgeries for patients with osteoarthritis because
most of the patients in orthopedic surgery exhibit hip problems which directly relates to this
project and the project goals. Continued involvement and devotion to the site exposed the effects
of hip osteoarthritis and its effect on bone weakness leading to injury. Continued involvement at
the site revealed that bone weakness and injuries associated with the hip will be a problem for

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individuals later in life. Walking is an important activity in our daily lives and hip pain can
greatly limit our range of motion and decrease the quality of life.
Genetics, obesity, and age are the more common risk factors for developing hip os-
teoarthritis. Age is a significant risk factor for osteoarthritis because it effects how our muscu-
loskeletal system works. Joint tissues weaken due to cellar death as a result of aging causing a
loss in cartilage around the head of the femur which inserts into the acetabular cavity (Anderson
2010). Weakness of the musculoskeletal system increases the likelihood to develop osteoarthritis.
Although age is a risk factor that cannot be regulated, body weight can be maintained.
Obesity is an important risk factor that can be regulated. Due to an increase in the me-
chanical stresses experienced across the weight bearing joints of the hip joint complex, hip joint
degradation is likely to ensue. Overweight persons thus have an increased risk of developing hip
osteoarthritis (Felson 1996). Bilateral hip osteoarthritis is the most common to develop because
of the force distribution along the joints of the hip when performing exercises such as walking
(M. Halbert, personal communication, February 7, 2015). Although obesity is an important risk
factor, it is unique in that it can be manipulated to help prevent and treat osteoarthritis. However,
if a medical history of hip osteoarthritis is present, its development may be likely.
A risk factor that cannot be altered or manipulated is our genetics. Hip osteoarthritis is
twice as likely to occur due to relatives compared to healthy individuals (Abramson et al. 2009).
Its genetic heritability is around 60%. This number is alarmingly high, meaning that there is
nearly a two-thirds chance to pass osteoarthritis onto ones offspring. Genetics was discovered as
a risk factor due to genome scans which were able to identify certain chromosomes such as 1 and
2 ( Fernández-Moreno 2008). Although these tests are expensive, they have been able to relate

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genetic predisposition with hip osteoarthritis which is very valuable information. Therefore, hip
osteoarthritis is very specific, especially during later years of life, which is why it is important to
understand how treatment options can help improve the quality of life for patients exhibiting hip
osteoarthritis.
Purpose of the Study
The purpose of this project is to determine how physical therapy has an effect on post op-
erative hip osteoarthritic patients by measuring patients range of motion. After completing the
Senior Project it will be determined if physical therapy helped patients regain some mobility
without exhibiting a great deal of pain.
Significance of the Study
The outcome from this study will give patients motivation to perform physical therapy in
order to improve their state of health by showing if physical therapy will help the patient gain
mobility and reduction in pain experienced in the hip. The importance in the results of the study
will allow elderly individuals better equip themselves with the care they need to live a healthy
and free lifestyle. In severe cases, surgery may be the only option for care, which may scare pa-
tients to decide to not go through with the surgery. However, by representing how physical ther-
apy will speed the recovery process and show a better state of health, wellbeing and mobility,
patients may consider total hip replacement as a more viable option. To prove that patients are
exhibiting a positive outcome, a researcher will observe physical therapists working with patients
after surgery who have hip osteoarthritis and record the pain levels through the WOMAC proto-
col during each trial. In addition, by using a goniometer, measurements will be made of each pa-
tients range of motion in order to indicate if progress was made.

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Hypothesis
My hypothesis of this project are as follows:
1. Different physical therapy programs are used to treat hip osteoarthritis.
2. Physical therapy helps post operative hip osteoarthritic patients improve range of motion
without exhibiting a great deal of pain.
Limitations of the study
Although I will be spending over 200 hours in Orthopedic Surgery at Inter-Community
Hospital, there will be many limitations to my study. These limitations include:
1. Constant rotation of patients in the hospital requiring a wide array of data collection from
multiple patients.
2. Matching schedules with on site supervisor to observe patient-doctor interaction vital to the
completion of the project.
3. Consent must be given due to patient-doctor confidentiality limiting the amount of data col-
lection on patients regarding personal information as well as observably therapy.
4. Time during the week to observe and assist at Inter-Community Hospital in Orthopedic
Surgery limiting data collection.
5. Inclusivity of the project regarding gender and age.
Definition of Terms

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Alleviate- To reduce the pain or trouble of something, to make something less painful, difficult,
or severe (Merriam-Webster Medical." N.p., n.d. Web).
Bilateral- Use of both limbs together (Hamill, Knutzen, pg 121, 2009).
Cartilage- A strong but flexible material found made up of chondrocytes (Hamill, Knutzen, pg
48, 2009).
Deteriorate- To become worse as time passes (Merriam-Webster Medical." N.p., n.d. Web).
Dizygotic- Relating to twins derived from two separate zygotes, bearing the same genetic rela-
tionship as full sibs but sharing a common intrauterine environment (Medical Dictionary." Medi-
Lexicon. N.p., n.d. Web. 9 Feb. 2015).
Fracture- Culmination of micro trauma imposed upon the skeletal system when loading of the
system is so frequent that bone repair cannot keep up with the breakdown of bone tissue (Hamill,
Knutzen, pg 47, 2009).
Goniometer- An instrument for measuring angles (Cibulka et al., 2004).
Monozygotic- Derived from a single egg (Merriam-Webster Medical." N.p., n.d. Web).
NSAIDS- A nonsteroidal anti-inflammatory drug (Medical Dictionary." MediLexicon. N.p., n.d.
Web. 9 Feb. 2015).
Noninvasive- Not being or involving an invasive medical procedure, not tending to infiltrate and
destroy healthy tissue (Merriam-Webster Medical." N.p., n.d. Web).
Osteoarthritis- A disease that causes the joints to become very painful and stiff (Franklin
Hoaglund 2013).
Orthopedic Surgery- Branch of surgery concerned with conditions involving the musculoskele-
tal system (K. White, personal interview, February 22, 2015)

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Pelvic Girdle- Connects lower limbs to each other to the trunk establishing a link between ex-
tremities (Hamill, Knutzen, pg 188, 2009)
Pharmacological- The properties and reactions of drugs especially with relation to their thera-
peutic value (Medical Dictionary." MediLexicon. N.p., n.d. Web. 9 Feb. 2015).
Physiology- The branch of biology that deals with the normal functions of living organisms and
their parts (Medical Dictionary." MediLexicon. N.p., n.d. Web. 11 Feb. 2015).
Rehabilitation- Restoration, following disease, illness, or injury, of the ability to function in a
normal or near-normal manner (Medical Dictionary." MediLexicon. N.p., n.d. Web. 11 Feb.
2015).
Rheumatoid Arthritis- A usually chronic disease that is considered an autoimmune disease and
is characterized especially by pain, stiffness, inflammation, swelling, and sometimes destruction
of joints (Medical Dictionary." MediLexicon. N.p., n.d. Web. 11 Feb. 2015).
Skeletal System- The framework of the body, consisting of bones and other connective tissues,
which protects and supports the body tissues and internal organs (Hamill, Knutzen, pg 31, 2009).
Total Hip Replacement- A surgery to replace a diseased or injured hip joint. An artificial ball-
and-socket joint is inserted to make a new hip. It can be done by full open surgery or a minimally
invasive technique (Kamimura, A 2014).
WOMAC- The Western Ontario and McMaster Universities osteoarthritis index, a self-reported
patient response outcome measure designed to determine patient response on 3 different func-
tional criteria or subsets, which include pain, stiffness, and physical function (Cibulka et al.,
2004).

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X-Ray- To examine and make images of by using X-rays (Medical Dictionary." MediLexicon.
N.p., n.d. Web. 11 Feb. 2015).
Chapter 2
Review of Literature

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erative hip osteoarthritic patients by measuring patients range of motion. Osteoarthritis is a very
severe disease and it is important to understand what factors contribute to its development as
well as how to cope and deal with the disease. Therefore, it is pivotal to understand the function
and structure of the hip, how age, genetics and obesity are associated with osteoarthritic devel-
opment, understand the range of motion of osteoarthritic and normal hip, and
possible treatment options for those who currently have the disease. Although age, genetics, and
obesity will not be specifically tested in this study, it is important to understand their role in the
development of hip osteoarthritis.
Hip
The hip is one of the bodies largest weight bearing joints. The ball and socket joint is
what helps the hip remain stable even during twisting and extreme ranges of motion. A healthy
hip allows one to walk, squat, and turn without pain (Hamill, Knutzen 2009). The pelvic girdle is
the site for muscular attachment and it must be oriented in a favorable position to ensure move-
ment. The pelvic girdle and hip joints play an important role for lower extremity movement al-
lowing the hip to move within three degrees of freedom, which is articulated between the acetab-
ulum on the pelvis and the head of the femur (Hamill, Knutzen 2009). The head of the femur sits
into the acetabular cavity giving it a large surface contact area. Both the head of the femur and
acetabulum have large amounts of spongy bone, therefore the force is easily distributed by the
hip joint. What helps move the hip are two massive muscles, the gluteus maximus and the ham-
strings. They combine to produce forces strong enough for hip extension (Floyd 2012). Hip flex-
ion is produced by many muscles, however they do so secondarily to other main functional roles.

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Strength produced for hip flexion is generated primarily by the ilipsoas muscle. These muscles
are easily trained performing daily activities which are vital for proper hip function. Although
muscular damage is rare, age can have a detrimental effect on the functioning of the hip joint and
muscle complex due to degeneration.
Age
One of the most common disorders associated with age is Osteoarthritis. Aging affects
the musculoskeletal system by increasing the propensity for osteoarthritis. Weakening of joint
tissue due to age is a result of cellular death. The degenerative disease leads to a loss in articular
cartilage which is contributed to wear and tear of tissues. Living cells normally respond to me-
chanical stimulation to help maintain joint homeostasis (Anderson 2010). However, weakness of
the musculoskeletal system increases the susceptibility to develop osteoarthritis. A systematic
review by Dagenais et al., reported a higher prevalence of hip osteoarthritis in a group of 5.9% in
their 45-54 age group and increased to 17% in a 75 and above age group. Age-related loss in the
ability of cells and tissues in the body to maintain homeostasis, particularly when placed under
stress may result in osteoarthritis. The chondrocyte is one type of cell present in the articular car-
tilage that is responsible for the synthesis and breakdown of the cartilaginous extracellular matrix
(Anderson 2010). Osteoarthritic cartilage has an excess of catabolic signals promoting the degra-
dation of chondrocytes disrupting the homeostatic process. A reduction in growth factors such as
IGF-1 which are important for anabolic processes of cartilage, also lead to a decline in chondro-
cyte response (Hamill, Knutzen 2009). Although age is one of the greatest risk factors for the de-
velopment of osteoarthritis, it is inaccurate to leave out other important variables from the equa-
tion.

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Genetics
A genetic disposition for osteoarthritis has been shown through a number of sources in-
cluding epidemiological studies of different family histories, twin studies and even rare genetic
disorders. Studies have shown that osteoarthritis is twice as likely to occur in first degree rela-
tives as in control individuals (Abramson et al. 2009). Twin pair and family risk studies have also
indicated that there is a significantly higher rate of development for osteoarthritis in monozygotic
twins than between diyzgotic twins. Genetic heritability of developing osteoarthritis in just the
hip is around 60%, however when combined with other data including the knee, hip, and spine,
heritability may be 50% or more, which indicates that half of the variations are susceptible to the
disease due to genetic factors (Spector et al. 2004). Moreover, there has also been research to
show that several genes that encode proteins of the extra-cellular matrix may be associated with
an early onset of osteoarthritis. Inherited forms of osteoarthritis may be caused by mutations on
many other genes that are expressed in the cartilage, including encoding types IV, V, and VI col-
lagens (Abramson et al. 2009). Evidence from mouse models has indicated that genetic disorders
affecting the subchondral bone can cause osteoarthritis as well. These mice with a mutation of
TGF-β binding protein-3 which regulates the activation of TGF-β developed osteoarthritis
(Abramson et al. 2009). To gather more conclusive data additional population studies have been
performed to identify additional genes involved in disease risk.
Genome-wide linkage scans have been able to highlight certain chromosomes that may
be harboring one or more susceptible genes. Chromosomes were identified through a genome
wide linkage scan which revealed a relationship between 12 chromosomes: 1, 2, 4, 6, 7, 9, 11-13,
16, 19, and X (Fernández-Moreno 2008). A more focused analysis revealed that chromosomes

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2q, 7p, 9q, 11q, and 16p were associated to be greater gene carriers involved in osteoarthritis
(Abramson et al. 2009, Spector et al. 2004, Hoaglund 2013, Fernández-Moreno et al. 2008). Ad-
ditional tests including a fluorescent in situ hybridization (FISH) analysis have also revealed that
46% of their patients expressed abnormalities on chromosomes 7, X, or Y. Hip osteoarthritis
among the patients was associated with trisomy 7, which is an extra chromosome 7, which was
present in 35% of the patients with chromosomal abnormalities (Castellanos et al. 2004). None
of the patients who participated as controls had abnormalities in the chromosomes analyzed.
There are many other genetic factors contributing to the development of hip osteoarthritis, how-
ever chromosomal abnormalities and gene encoding problems are of the greatest genetic contrib-
utors. Our genetic predisposition may be beyond our reach of control to prevent osteoarthritis,
however living a healthy lifestyle is not.
Obesity
Another important risk factor that can be regulated is obesity, or being overweight. An
increase in the mechanical stress and forces across weight bearing joints such as the pelvic girdle
and hip joint complex are the primary factors leading to joint degradation. Overweight persons
do have a higher than expected risk of hip osteoarthritis, however some studies have been incon-
sistent reporting that there may be no association. Studies with large enough sample sizes have
been able to show a correlation between obesity and hip osteoarthritis. In a study with 5000
women with hip x-rays from the study of Osteoporotic Fractures, obesity was in congruence with
an 80% increase in the odds of bilateral hip osteoarthritis (Felson 1996). Unilateral hip os-
teoarthritis was only half that showing that subjects are more likely to develop hip osteoarthritis
in both parts of the hip rather than one. The most logical reason why the hip would be affected

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bilaterally is due to the amount of force across the joint. Excessive force would induce cartilage
breakdown simply because of excess force. Force is distributed equally along the joints when
performing simple movements such as walking, leading to a bilateral hip osteoarthritis. Obesity
is an important risk factor, but it can be manipulated to prevent and alleviate osteoarthritis and its
symptoms. However, if not taken into consideration, overall hip mobility and movement will be
hindered due to cartilaginous breakdown, leading to possible immobility of the hip.
Range of Motion
The pelvis is used to help transfer weight from the axial skeleton to the appendicular por-
tion of the body when experiencing increased forces from walking and standing. The hip must
be able to rotate within its normal range from 0-125 degrees of flexion and within 5-40 degrees
of extension in order for a proper walking cycle during gait to be achieved. Flexion is limited
primarily by soft tissue, but can be increased if the pelvis tilts posteriorly while extension is lim-
ited by the anterior capsule (Hamill, Knutzen 2009). The hips specific range was measured by
having subjects perform feasible and noninvasive tests. Positions included the subjects laying in
a prone, supine, upright positions (R. A. Elson et al. 2008). Age and BMI restriction were placed
to narrow down the search for subjects and produce comparable, reliable results. Body mass in-
dices ranged from 20-25 percent to represent a moderate obese population. The BMI was com-
pared to an age group of subjects of 20-60 years of age. The participants all had no prior hip or
lower extremity disorders or injuries and therefore resembled a hip range when flexed to be of
80-140 degrees and 5-40 degrees when extended (P. Kouyoumdjian et al. 2012). In addition to
hip flexion and extension, external and internal hip rotation did not differ among the participating
subjects with a value of 30-50 degrees. Symmetric balance was noticed in more than 60% of the

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subjects, in contrast subjects with osteoarthritis displayed significant range of motion differences
when completing similar tests.
Subjects with diagnosed osteoarthritis displayed what is known as flexion contracture,
resulting in subjects unable to reach the defined position for extension of the hip. Approximately
72.5% of the patients were observed to experience flexion contracture which results in a signifi-
cant reduction in the range of motion of the hip (M. P. M. Steultjens et al. 1999). Knee flexion
ranged from 25-146 degrees while hip extension ranged from -18-30, showing a discrepancy
when compared to those with normal functioning hips. A study performed by Hurwitz also com-
pared patients with unilateral osteoarthritis of the hip to a group of normal subjects with a similar
age distribution. Patients with osteoarthritis walked with a decreased range of motion of 17 de-
grees and decreased external extension (D. E. Hurwitz et al 1997). Therefore, the range of mo-
tion of the hip is significantly hindered when subjects contract osteoarthritis. Although mobility
of the hip is reduced to a great extent, there are many therapeutic options to choose from to im-
prove ones maneuverability.
Treatment
Osteoarthritis is extremely painful and the risk factors may seem like the disease cannot
be avoided, but there is still hope. There are a plethora of treatment options ranging from non-
surgical treatments to dieting. In the early stages of the disease, non-pharmacological and phar-
macological treatments are recommended. Non-pharmacologic interventions include patient edu-
cation, heat and cold therapies, weight loss, exercise, physical therapy, and occupational therapy.
For the initial management of hip osteoarthritis, medications such as acetaminophen, oral
NSAIDS, tramadol, and intra-articular corticosteroid injections also may be used (K. White, per-

17
sonal communication, February 28, 2015). Among these treatment options, weight loss due to
exercise is one of the more conventional forms of osteoarthritis therapies.
Weight loss reduces the amount of stress placed on weight bearing joints of the body. In-
dividuals with a BMI of over 25kg/m^2 participate in a self reported program to measure pain
and walking as a quantitative measure of their functioning. The results showed a 32.6% im-
provement in physical function after 8 months (Paans 2013). Forms of exercise can include
aquatic exercises, lower body strengthening and stretching exercises such as leg press, squats,
and walking on the treadmill. Recurring treatment may be necessary depending on the rate of
improvement for each participant and if further injury occurs (Molina 2008). If exercise and
weight loss do not have a positive effect on the individuals body, a more aggressive approach
may be necessary.
Hip replacement surgery removes the damaged joint lining and replaces the joint surfaces
with an artificial impact which would function similar to a normal hip. When the joint is severely
damaged due to arthritis, hip replacement surgery is the best option. The surgery uses metal, ce-
ramic, or plastic parts to replace the ball at the upper end of the femur and resurface the hip
socket in the pelvic bone. The cartilage is removed from the acetabulum and the upper end of the
femur and replaced with what is known as femoral prosthesis and acetabular prosthesis. Once the
prosthesis are inserted into the site, it is cemented by using methylmethacrylate. A cementless
prothesis may also be used to allow bony ingrowth which as been shown to last longer in dura-
tion. There are different methods of approach for total hip replacement, however each method
has its advantages and disadvantages.

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In a five year study, a total of 1089 total hip replacement patients participated in a pro-
gram to compare the benefits of the anterolateral approach and posterior approach. The positive
and negative results of each approach have been well documented and thus the choice of which
approach is used is largely depended on the surgeons preference. At the end of the study, there
were no differences in change in the Oxford hip score, dislocation and revision rates between
both groups. The dislocation rates for the anterolateral group was around 1.7% while the posteri-
or group exhibited 2.3%, which represent no significant value to which approach is used (Palan
et al. 2008). Moreover, if prior treatment options have been unsuccessful, total hip replacement
surgery may be a viable option for those seeking better treatment.
Summary
Once cartilage surrounding the hip and severe osteoarthritis takes full effect, treatment
options may only be limited to surgery. However, through exercise, weight loss can be induced
which may slow the disease and mobility may be kept at normal levels. Unless genetically pre-
disposed with the disease, it can be managed through weight control and monitoring high impact
movements. Risk factors such as age, genetics, and obesity may lead to hip osteoarthritis de-
creasing the range of motion, the functionality of the hip can be maintained through treatment
and rehabilitation. Although age, genetics, and obesity will not be specifically tested in this
study, it is important to understand their role in the development of hip osteoarthritis.20Methods
and Procedures

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Chapter 3
Methods and Procedures
erative hip osteoarthritic patients by measuring patients range of motion. After completing the
Senior Project I will be able to determine if physical therapy helped patients regain some mobili-

20
ty without exhibiting a great deal of pain. The patients with hip osteoarthritis were all treated
similarly. Five patients were chosen for the project, however they will not be named due to pa-
tient confidentiality. The patients varied in sex, occupation, severity, and ethnicity but were simi-
lar in age. This project was completed through a clinical observation format of over 200 hours at
Inter-Community Hospital apart of Citrus Valley Health Partners, Orthopedic Surgery in Covina
and was Supervised by Melissa Halbert.
The purpose of this next section is to show how this project will be conducted. The
project will include information regarding participating subjects, the location of the project, the
patients treatments, how the data was collected, the projects expected outcomes, and how the
data will be analyzed.
Subjects Characteristics
The subjects all differed in occupation, sex, ethnicity, severity, and range of motion. The
patients registered pain level was recorded on a 0-10 scale with 0 as no pain experienced and 10
the worst pain experienced. The hips range of motion before physical therapy treatment is also
recorded in degrees in the order of internal rotation, external rotation, flexion, and extension. The
five subjects have been grouped in a table below indicating their individual characteristics.
Figure 1. Characteristics of five patients with hip osteoarthritis
Patient Age
Number
Occupation Sex Ethnicity Severity-
rated on a
0-10 scale
Range of
Motion
(degrees)
1
45
Cashier Female Hispanic Right hip: 7 60,50,54,31
2
47
Account
executive
Male African
American
Right hip: 6 20,61,90,35

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Location of Project
This project was completed through a clinical observation format of over 200 hours at
Inter-Community Hospital apart of Citrus Valley Health Partners, Orthopedic Surgery in Covina
and was Supervised by Melissa Halbert. The floor focuses on the rehabilitation, treatment, and
acute care of patients with hip osteoarthritis. The use of both surgical and nonsurgical means are
used to treat musculoskeletal trauma and degenerative diseases on the floor. The site includes
Registered Nurses, Certified Nursing Assistants, Imaging Assistants, Physicians, and Physical
Therapists that routinely work on the floor.
Due to the high trafficking of patients, the floor can be busy during peak hours, therefore
the researcher played a vital role for the comfort and rehabilitation for the patients when able.
Consent was giving in order to observe treatment and when allowed, the researcher was able to
assist the patients in their rehabilitation programs. Rehabilitation included assisting the physical
therapist walk patients to determine improvements in range of motion and gait, assisting in
stretching exercises in and out of the bed as well as strengthening exercises. Proper post opera-
tive positioning of the patient was also extremely vital to their comfort and care of the hip. While
the patients are positioned in their beds, pillows were used to help keep the knees separated. This
3
52
Retail Male Mandarin Left hip: 8 35,54,80,40
4
49
Health care Female Caucasian Right hip: 6 15, 65,83,35
5
50
Mail Room Male Hispanic Left hip: 7 23,58,86,29
Patient Age
Number
Occupation Sex Ethnicity Severity-
rated on a
0-10 scale
Range of
Motion
(degrees)

22
allows the hip to stay in an abducted position. The purpose is to prevent the patient from crossing
their legs. When the patient is sitting up in bed or standing, it is very important that the patient
does not lean forward, bend over or stand with their toes turned in. Any of these actions could
increase the risk of injury and dislocation of the hip. It was my job to make sure the patients did
not attempt any of these actions that could further injure their hip. Movement after hip replace-
ment surgery has to be at the patients own pace to avoid femoral head damage. The physical
therapist provides a very detailed description of what they can and cannot do on their own as
well as provide a series of visual sheets to assist the patient in understanding the movements that
they are allowed to perform. With the help of the physical therapists and nurses I was able to ob-
serve and experience how a rehabilitation program was administered, how it progressed, and
skills necessary to ensure each patient completed each physically therapy bout with the goal of
improving their range of motion and pain levels.
Treatment
An initial evaluation was taken regarding each patient before treatment could ensue. This
is called a diagnosis. Due to hospital policy, the researcher was not present in the private room
during initial evaluations. However, Melissa did explain the general outline for an initial evalua-
tion to determine osteoarthritic symptoms. The initial assessment comprises a medical history
questionnaire, physical examination and analysis. History taking and physical examination are
performed to get a comprehensive overview of the patient’s health status. This assessment in-
cludes screening for red flags. The doctor must be consulted in case of a red flag after delibera-
tion with the patient. With the analysis, the patient’s main limitations and impairments are priori-
tized, and treatment goals and a treatment plan are formulated, and in close collaboration with

23
the patient, treatment goals are set, with the focus on limitations of activity and restriction in par-
ticipation. The Doctor or physical therapist would ask the patient important information about
possible causes of symptoms by discussing their medical history.
Identifying the duration of symptoms as well as joint stiffness during the morning periods
is important to consider when evaluating a patient for osteoarthritis. After long sedentary periods,
pain usually ensues when attempting minor movements. To help single out osteoarthritis, the pa-
tient is asked about general symptoms that may affect the whole body such as fatigue, weight
loss, and fever. Osteoarthritis usually doesn't cause whole body symptoms, therefore these symp-
toms may not indicate osteoarthritis. The doctor then inquires the patient of their family history
of arthritis, recent or past injuries to the affected joints especially during repetitive motions. A
recent injury may mean painful symptoms are related to an injury, not to a disease. After gather-
ing the necessary medical history from the patient, a physical examination is performed. The
doctor will look at, feel and move each joint, evaluating it for swelling, warmth or tenderness.
Palpitations of the hip help determine its range of motion and level of pain. The doctor will also
look for any signs of unequal leg lengths, muscle weakness, or muscle wasting. A normal joint is
not painful, tender or swollen, and has full range of motion and appears structurally normal. In
an abnormal joint, there will be indications of tenderness or swelling and pain which can limit
movement or a creaking noise or feeling when the joints are moved.
The therapist should assess the patient’s health status primarily in terms of activity limita-
tions and participation restrictions. In addition, the therapist may also assess impairments of
body function and structure, as well as personal and environmental factors, as these relate to the
limitations and restrictions. Based on the information obtained in the initial assessment, individ-

24
ual treatment goals are discussed. Treatment goals are set to focus on limitations of activities and
restriction in participation. The goals are aimed at reducing pain and improving physical func-
tioning. Programs include aerobic and muscle strengthening exercises and range of motion func-
tional exercises. The length of treatment is variable and may not require supervision. If pain is in
combination with joint mobility then manual therapy is highly recommended. It should comprise
manipulation, manual traction, and muscle stretching exercises.
Furthermore, imaging tests of the affected joint are obtained through x-rays and magnetic
resonance imaging. Cartilage doesn’t show up on x-ray images, however cartilage loss is re-
vealed by narrowing of the space between the bones in your joint. An x-ray may also show bone
spurs around a joint. Most people exhibit x-ray evidence of osteoarthritis before they experience
any symptoms. MRI’s are also used to help display detailed images of bone and soft tissues in-
cluding cartilage by the use of radio waves with a strong magnetic field. An MRI isn’t commonly
needed in a diagnosis, but it may help provide more information in complex cases.
Following the initial assessment and diagnosis, if imaging tests show signs of severe loss of joint
cartilage in the hip, surgery is highly recommended. Before surgery, the doctor will explain in
detail the procedure. The patient will be asked to sign a consent form that gives the doctor per-
mission to do the procedure. Fasting will be required for a period of eight hours before the pro-
cedure and a sedative will be given prior to the procedure. The patients physical therapist will
meet prior to surgery to discuss rehabilitation one last time.
Hip replacement surgery follows a very straight forward process. The patients clothing is
removed and given a gown to wear while an intravenous line would be started on the arm or
hand. The anesthesiologist will continuously monitor the patients heart rate, blood pressure,

25
breathing, and blood oxygen level during surgery. The doctor will make an incision in the hip
area and begin removing the damaged parts of the hip and replace them with a prosthesis. The
hip prosthesis is made up of a stem that goes into the femur, the ball that fits into the stem, and
the cup that is inserted into the socket of the hip joint. The stem and cup are both made of metal
while the ball metal or ceramic. The incision will be closed following the completion of the
surgery with stitches or surgical staples. A sterile bandage and drain will be placed on the inci-
sion site to prevent infection.
Succeeding the surgical procedure, the patient will be taken to the recovery room for ob-
servation. Once their blood pressure, pulse and breathing are stable and they are alert, they are
taken to the hospital room. Hip replacement surgery usually requires an in-hospital stay for sev-
eral days or longer depending on their condition. It is important to begin moving the new joint
after surgery, thus physical therapy will begin as soon as possible. Medications such as acetome-
tophine are given to help reduce pain so that the patient can participate in the exercise program.
An exercise plan will be given to follow in the hospital and after discharge to continue improve-
ment in muscle strength and range of motion.
Exercises can be performed in their bed or standing. If the patient is unable to stand or
move out of their bed, rotation and lift exercises can be implemented until the patient has gained
the strength to do so. Exercises given to patients who are bed ridden help improve strength and
hip mobility. These exercises include ankle pumps, quad sets, glut sets, hamstring sets, and heel
slides. Ankle pumps involve the patient moving their foot up and down in circles while quad sets
require the patient to press their knee into the bed while tightening their thigh muscles. Ham-
string sets require the patient to dig their heels into the bed with their knee slightly bent and heel

26
slides involve the heel to be slid towards themselves bending the knee as much as possible and
holding for five seconds. These exercises are performed until the patient is strong enough to per-
form standing exercises. Repetitions and trials are determined by the physical therapist by ob-
serving the patients improvement.
Observable improvement allows the patient to begin standing exercises to demonstrate
weight bearing ability. Types of standing exercising including stationary marching, kick backs,
and hip abductor exercises. When the patient is instructed to kick backwards, their leg must be
held for a brief moment. The patients strength indicates if the patient is ready to begin walking
sessions. The patient must be supervised while walking in order to prevent falls and further in-
jury to the hip joint. The use of devices such as a walker, cane and crutches are used to help sta-
bilize the patient to distribute weight across the joint. A checklist is completed to log the patients
distance traveled, mobility and gait with the degree of assistance, and any precautions. Stretching
can be performed before and after exercise bouts under the discretion of the patient if it is tolera-
ble. Possible stretches that the patient will need to complete during their prolonged physical ther-
apy session are hamstring stretches, calf stretches, and hip flexor stretches. All stretches and ex-
ercises are monitored by the physical therapist and pain levels are taken into account to deter-
mine the intensity, speed, and frequency of each session.
Data Collection
During the course of the experiment, different variables will be collected in order to de-
termine how physical therapy has an effect on post operative hip osteoarthritic patients. The vari-
ables to be obtained are range of motion, pain, and weight. Pre and post measurements will be

27
recorded in order to prove whether or not physical therapy had an effect on the patients with hip
osteoarthritis.
Instruments Used
For the evaluation of treatment, several measurement instruments were available to use.
The timed Up and Go test or TUG, measures the time in seconds in which the patient stands up
from a chair, walks three meters, turns around, walks back and sits down on the chair. The test
must take place at a comfortable speed. A measurement instrument to measure walking and aero-
bic capacity is the six minute walk test. During the six minutes walk test the patient has to walk
six minutes at a self chosen walking speed and they have to try to overcome as much distance as
possible without running. The accomplished distance is the total distance at the end of the six
minutes. Range of Motion is measured by the use of goniometry, which is a measuring device
used to measure the precise angular position. A goniometer is used to accurately track the
progress of the rehabilitation process. Finally, a test measuring the limitations in activities as well
as pain and stiffness is the Western Ontario and McMaster Universities Osteoarthritis index test,
otherwise known as WOMAC. The use of these tests allows the physical therapist to accurately
measure, observe, and alter the rehabilitation program for the patient organically, allowing for
optimal treatment.
Analysis of Data
Upon the completion of each session of physical therapy with the patient, different values
will be recorded based off their performance. Numerical data such as angles when measuring the
range of motion of the hip after physical therapy will be recorded. Percentages can then be taken
to determine if there was a percentage increase or decrease which would identify if a positive or

28
negative outcome ensued. Pre and post test measurements will also be taken on the injured and
uninjured sides of the hip to distinguish range of motion differences and pain levels when experi-
encing movement. The use of the WOMAC test as described in the previous section will provide
information regarding the patients pain and stiffness of the hip and will also be recorded numeri-
cally. The measurement outcomes will determine if the hypotheses of the project were met or
rejected by analyzing pain levels and angular change of the hip.
The use of graphs, charts, and tables will be used to demonstrate visually a change in pain
levels as well as range of motion of the hip for each individual patient. A comparison can then be
made between each patient to determine the effect of severity on the patients recovery speed. The
graphical representations of data will either represent or reject previously stated hypothesis and
promote or denote the use of physical therapy for patients post operation. The data analysis will
provide meaningful results for patients, citizens and healthcare professionals in the use of physi-
cal therapy on post operative hip osteoarthritis patients.
Summary
Following the completion of each patients physical therapy sessions, a compilation of
data regarding range of motion and pain experienced can be graphically represented to determine
the outcome and effect of the rehabilitation. The five patients that were chosen to participate in
the experiment will be used to show if physical therapy had an effect on post operative hip os-
teoarthritic patients by using a goniometer, WOMAC scale and other measuring devices as speci-
fied in the instruments section of this paper. The raw data is displayed in the following chapter
regarding each patients pain and range of motion measurements.

30
Chapter 4
Upon reaching the final stages of the project, similarities and differences were observed
between reviewed literature and case studies regarding patients with hip osteoarthritis. Variables
that were observed included age, obesity, range of motion, and treatment. Variables that were un-
able to be observed and compared to research data included genetics and the functionality of the
hip.
Age comparison
Osteoarthritis is a disorder that is very prevalent in elderly populations. Therefore the ages of the
participating subjects very closely related to the material researched. A systematic review by Da-
genais et al., reported a higher prevalence of hip osteoarthritis in a group of 5.9% in their 45-54
age group and increased to 17% in a 75 and above age group. These figures coincide with the age
group gathered in the study. Those within the age range of 45-54 are more susceptible to devel-
oping osteoarthritis due to a disruption in the equilibrium and homeostasis that comes with aging
(Anderson 2010). The subjects in the study matched the age characteristics of those in the litera-
ture review showing that the researcher observed subjects that coincided with the actual research
material. All of the subjects in the age group were diagnosed to have hip osteoarthritis. Subjects
below the age of 44 and above the age of 56 were not diagnosed to have hip osteoarthritis at In-
ter-Community Hospital confirming the studies sited in the research portion of this paper.
Obese Comparison
Patients diagnosed with hip osteoarthritis are not only elderly, they are also unfortunately
over weight. Overweight persons do have a higher than expected risk of hip osteoarthritis due to
the increase weight bearing on their joints. Studies that are able to produce large enough sample

31
sizes have been able to show a correlation between obesity and hip osteoarthritis. In a study with
5000 women with hip x-rays from the study of Osteoporotic Fractures, obesity was in congru-
ence with an 80% increase in the odds of bilateral hip osteoarthritis (Felson 1996). Men and
women alike at Inter-community Hospital are affected by hip osteoarthritis due to their weight.
Every patient diagnosed with hip osteoarthritis was overweight with a BMI of over 30, which is
a figure representing an obese population. The patients that participated in the study also had bi-
lateral hip osteoarthritis. Bilateral hip osteoarthritis lead to increased falls and fractures during
rehabilitation, which is a result of obesity.
Range of Motion Comparison
The range of motion when experiencing hip osteoarthritis is significantly limited and re-
duced due to the stiffness of the joint. What is known as hip flexion contracture is usually expe-
rienced in 72.5% of the patients (M. P. M. Steultjens et al. 1999). The only discrepancy between
the case study and actually observed data at Inter-community hospital is in the percentage of pa-
tients experiencing hip flexion contracture. Only 60% or 3 out of the 5 patients displayed this
problem, representing a difference between researched case studies and observed data. The only
similarity was noted in the hips range of motion when walking. The researcher observed a de-
crease in 15-19.5 degrees in the range motion of the hip which matched D. E. Hurwitz et al study
of a 17 degree decrease. Therefore the rehabilitation site was still aptly able to provide an accu-
rate representation of the range of motion of the hip when compared to alternative experimental
results.
Treatment Comparison

32
Treatment is usually variable for the type of injury or severity of an injury. However in
regards to hip osteoarthritis, treatment remains relatively the same. When comparing composi-
tional and professional case studies to the rehabilitation programs performed at Inter-community
Hospital, there were little to no differences. Hip replacement surgery is most commonly an op-
tion for those patients who are diagnosed as a more severe case. These patients include those
have imaging tests that show severe signs of joint cartilage loss in the hip. Every patient is re-
quired to go through an initial assessment prior to treatment to identify the patients as mild or
severe cases which would determine the type of treatment to be given. The case studies and
physical therapists both followed a strict set of guidelines to lead to a decision on how their giv-
en patients will be treated. Health status, symptoms, imaging tests, and multiple conferences are
held leading into treatment. Once a consensus has been met, treatment may begin. Treatment of
the hip is very straightforward and did not differ between observed and researched data. Exercis-
es such as ankle pumps, quad sets, marching, and various hip abductor exercises are all available
for a physical therapists to use on a patient with hip osteoarthritis. Treatment for patients diag-
nosed with the disease are generally treated similarly, differences are discussed during the con-
ferencing sessions held between the patients family and physical therapist. Therefore, treatment
options are all the same when it comes to previously diagnosed hip osteoarthritic patients. The
only reason for change is due to a specific treatment option not directly benefitting the patient,
requiring more consulting sessions to gear treatment towards the patients goals.
Summary

33
Proponents against the completed study can be reassured that the observed data closely
matched professional literature articles, reviews and experiments. The researcher was able to
gather observable data that did not differ from previous case studies and literature, showing the
success in gathering relevant and valuable data. All goals in the study were met as well as a
comparison between research and observations representing that Inter-Community Hospital fol-
lows similar guidelines as performed in research studies.
Chapter 5

34
Conclusion
Completing this project had its challenges, however the experience and knowledge
gained from it was worth the time and effort. Under the supervision of Melissa, I was able to
gain valuable knowledge pertaining to the medical field that I did not expect to learn once I start-
ed my hours at Inter-community hospital. I realized that there is still a vast amount of informa-
tion that I must learn before I start my journey into the medical field. A task that I was required
to do hourly was taking vital signs of each patient. The importance of these readings gave nurses,
physicians, and physical therapists the level of well being of each patient, allowing them to prop-
erly diagnose and treat each patient as an individual case. The tests that I performed on each pa-
tient included taking blood pressure measurements, oxygen saturation levels, temperature in the
armpit (auxiliary) and oral, pain levels, respiration rate, and heart rate. In a class room setting,
Kinesiology has taught me how to measure blood pressure and heart rate, however I was unable
to demonstrate and train these skills in an applied and professional setting. I can now say that I
am confident in completing these tasks in under a minute whereas when I first started my obser-
vation hours it took me roughly 5-6 minutes.
Regarding the physical therapy aspect during my time at Inter-community hospital, I
learned the importance of time. Patience is extremely important when it comes to the treatment
of each patient because each individual is in rehabilitation for a different cause as well as severi-
ty in regards to their hip osteoarthritis. Pacing is also very important because most of the patients
were unable to walk for a period of 1-2 weeks after surgery and were forced to perform exercises
in bed. Therefore these patients had to relearn the proper mechanics of walking which required
longer and less intensive treatment options.

35
Goniometry is very new to me, however at my site I was able to hone my skills by ob-
serving and assisting with the measurements of each patients range of motion. Acquiring the
range of motion for each patient is very important to asses the level of success the physical ther-
apy program had or evaluate the patient for a different treatment. The goniometer is a very vital
tool for medical field professionals specifically physical therapists in treating and diagnosing pa-
tients for care.
Concluding the project, I set several goals for myself to accomplish and I believe I was
able to meet every goal. My first goal was to understand the theory and application of an initial
evaluation. Although lengthy, the initial assessment is required in order to understand the patients
well being and mode of action. The initial assessment comprises a medical history questionnaire,
physical examination and analysis, all of which play an equal and important role in developing
an overview of the patients status. Concluding the initial assessment and evaluation, the patient is
then given options as to how they want to approach the problem. These are known as counseling
sessions which include the patient, their family and the physical therapist. Once a consensus has
been reached, treatment may begin.
I also wanted to examine how the patients severity, age, occupation, and range of motion
altered the rehabilitation process. These variables were very closely related in the sense that as
the patients got older, the severity increased and the range of motion decreased. My site was
mostly comprised of elderly patients, therefore they were at a very high risk of falling, making
maneuverability difficult and some treatment options not viable until a later time. Many exercis-
es for elderly patients were performed in their bed or if they were able, in a wheel chair stationed
by their bedside. Treatment options were kept the same until the patient was either no longer able

36
to perform them or no improvement was made over the course of the treatment. Therefore, some
patients would be required to participate in physical therapy for a longer period of time if initial
treatment was not successful as per the goals set by the patient in their initial evaluation.
The main outlook and goal of my project was to assist in the rehabilitative process. I am
not professionally trained to assist the physical therapists in their exercise programs, I was able
to observe and provide minor assistance when ambulating patients and assisting with bed to gur-
ney transfers as well as bed to standing positions. The minor assistance I provided allowed the
physical therapists to hone in on the needs of the patient to a higher degree, allowing for a
smoother transition between exercises as well as rest periods. Although I was not able to provide
as much assistance as possible due to my lack of training, the experience that I acquired through
observation of the physical therapy programs broadened my knowledge.
The last and most important goal that I set forth to complete was to improve my ability to
interact with patients. I believed this to be my hardest task during my project. Although I consid-
er myself a social person, forcing a conversation with someone you have never met in an envi-
ronment that may not be considered safe and comfortable to the patient is difficult. The patients
are constantly bombarded with questions, exercises, getting poked and prodded with needles,
sticking to a nutrition strict diet as well as being medicated. These factors come into play daily as
soon as they wake up until they fall asleep. This creates unneeded stress and anxiety in the lives
of the patients who are stuck in rehabilitation until they recover to a level to where they can per-
form day to day tasks on their own. Aside from assisting physical therapists with treatment op-
tions and programs, my job was to ensure each patients stay and experience was a positive one. I
therefore had to adapt to an environment that I was not accustomed to. I learned how to think on

37
my feet as well as spark a conversation about anything that the patient would be willing to talk
about. Even if I knew nothing about the topic, I attempted to maintain a conversation to show
that I cared and wanted to spend time with them.
Medical personnel are constantly busy so the patients are unable to receive social contact
that will make them feel like they matter. I was able to improve my interactions with patients and
professional staff, allowing myself to have a more enjoyable experience as well as keeping the
patients feeling comfortable and safe throughout the day.
Overall, I would recommend my site at Inter-community hospital because it provides
hands on experience and a professional environment where students can apply themselves and
become more knowledgeable in their field of study. Inter-community hospital is not limited to
rehabilitation, its departments extend to nutrition, medical surgery, emergency room and opera-
tion room to include a few. If an individual has the aspiration to increase their involvement and
extend their knowledge base in the medical field, I would highly recommend my site to those
who are willing to put in the work.
References

38
A. Shane Anderson, Richard F. Loeser, Why is osteoarthritis an age-related disease?, Best
Practice & Research Clinical Rheumatology, Volume 24, Issue 1, February 2010, Pages
15-26
Abramson, Steven B., and Mukundan Attur. "Developments in the Scientific Understanding of
Osteoarthritis." Medscape Multispecialty. Medscape, 2009. Web
Cibulka, Michael T., and Julie Threlkeld. Journal of Orthopedic & Sports Physical Therapy 34.8
(2004): n. pag. The Early Clinical Diagnosis of Osteoarthritis of the Hip. Web.
Elhadi Sariali, Alexandre Mouttet, Gilles Pasquier, Ernesto Durante, Three-Dimensional Hip
Anatomy in Osteoarthritis: Analysis of the Femoral Offset, The Journal of Arthroplasty,
Volume 24, Issue 6, September 2009, Pages 990-997
Felson, D. T. (1996). Does excess weight cause osteoarthritis and, if so, why? Annals of the
Rheumatic Diseases, 55(9), 668–670
Fernández-Moreno, M., Rego, I., Carreira-Garcia, V., & Blanco, F. J. (2008).
Genetics in Osteoarthritis. Current Genomics, 9(8), 542–547
Franklin T. Hoaglund, MD, Primary Osteoarthritis of the Hip: A Genetic Disease Caused by
European Genetic Variants. Journal of Bone Joint Surgery Am, 2013 Mar 06; 95 (5): 463
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Giori, N. J., & Trousdale, R. T. (2003). Acetabular retroversion is associated with osteoarthritis
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Hamill, Joseph, and Kathleen M. Knutzen. Biomechanical Basis of Human Movement. 3rd ed.
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Healthy, Older Adults. Disability and Rehabilitation, 36(4), 307–312
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Patients with Osteoarthritis. Rehabilitation Research and Practice, 2014
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Mariana V. Castellanos, Jesús M. Hernández, Luis Ramos, M. Belén González, Norma C.
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Osteoarthritis and Cartilage, Volume 12, Issue 12, December 2004, Pages 982-985
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